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Am Fam Physician. 2012;86(9):798-802

to the editor: A 40-year-old man with cryptorchidism that was corrected at 12 years of age presented in November 2010 with a four-year history of infertility. In November 2008, his sperm concentration was 3 million per mL, and motility was 30 percent. Microscopy revealed 2 percent normal morphology with a round cell count of 2 million per mL. Testicular ultrasonography and hormone levels were normal.

The patient was prescribed clomiphene (Clomid), 25 mg per day. Four months later, sperm concentration was 5 to 7 million per mL. Thirteen months after discontinuing clomiphene, bilateral varicoceles were diagnosed. At that time, sperm concentration was 4 million per mL, and motility was 63 percent.

Varicocelectomy and in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) were recommended. The patient and his 27-year-old wife consulted a physician who recommended dietary supplements. In November 2010, the patient began taking a formulation containing vitamin C, 1,000 mg; vitamin E, 400 IU; vitamin D, 800 IU; l-carnitine, 2,000 mg; l-arginine, 1,500 mg; vitamin B complex (containing folic acid, 1,600 mcg; vitamin B12, 1,000 mcg; niacin, 200 mg; biotin, 400 mcg; vitamin B6, 160 mg; and 100 mg each of thiamin, riboflavin, pantothenic acid, and paraaminobenzoic acid), and ginseng, 1,000 mg (Panax quinquefolius, dried root, Hsu Ginseng Enterprises, United States). All supplements were taken in divided doses twice daily.

After three months of treatment, sperm concentration normalized to 47 million per mL, and motility was 45 percent. In March 2011, co-enzyme Q10, 60 mg per day; zinc, 30 mg per day; and selenium, 100 mcg per day, were added to the regimen.

Pregnancy was confirmed in May 2011 and resulted in a successful cesarean delivery.

Subfertility affects one in every 20 men.1 One-half (51.2 percent) of infertility cases are associated with male factor infertility.2 A recent Cochrane systematic review of eight randomized controlled trials including 607 patients found no benefit to surgical varicocele treatment for subfertility.3 Conversely, a Cochrane review of 34 randomized controlled trials found that oral antioxidants were associated with a statistically significant increase in pregnancy rate (pooled odds ratio = 4.18; 95% confidence interval, 2.65 to 6.59).4

This case illustrates a couple who were advised to undergo surgical procedures but successfully achieved pregnancy with a mixture of benign, inexpensive supplements. Based on the existing evidence, perhaps other infertile couples should be offered a trial of dietary supplements before considering expensive and invasive procedures.

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This series is coordinated by Kenny Lin, MD, MPH, deputy editor.

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